HAL Id: hal-01316096
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vulnerabilities
Pierre Chauvin, Cécile Vuillermoz, Nathalie Simonnot, Frank Vanbiervliet,
Marie Vicart, Anne- Laure Macherey, Valérie Brunel
To cite this version:
Pierre Chauvin, Cécile Vuillermoz, Nathalie Simonnot, Frank Vanbiervliet, Marie Vicart, et al.. Access
to healthcare for people facing multiple health vulnerabilities: Obstacles in access to care for children
and pregnant women in Europe. 2015. �hal-01316096�
18
th
MAY 2015
20 14 © Denis R ouv R e.Doroftei, aged 10, has not been vaccinated:
“I still cannot go to school”
Saint-Denis - France
Access to
heAlthcAre
for
people
fAcing
multiple heAlth
vulnerAbilities
Obstacles in access
tO care fOr children
and pregnant wOmen
in eurOpe
Europe is the cradle of human rights. Indeed, the range of inter-national texts and State commitments that ensure people’s basic and universal rights is impressive. With regard to healthcare, Eu-ropean Union institutions recently reaffirmed their adherence to the values of universality, access to good quality care, equity and solidarity. Yet, this report shows how, in practice, these promises too often remain just words rather than effective progress. Doctors of the World – Médecins du monde (MdM) teams are dis-tinctive because they work both on international programmes and at home. Abroad, MdM is active in many of the places in the world from which people try and escape to survive. At home, we provide freely accessible frontline medical and social services to anyone who faces barriers to the mainstream healthcare system. This re-port is based on data collected in 2014 in face-to-face medical and social consultations with 23,040 people in 25 programmes/ cities in Belgium, France, Germany, Greece, the Netherlands, Spain, Sweden, Switzerland, the United Kingdom and Turkey. It paints a bleak picture of the ‘cradle of human rights’.
Increasingly dangerous migration routes due to tightening border controls, sub-standard detention conditions and a life in fear of being expelled await most of the migrants who decide to seek safety and refuge in Europe. They have in common with desti-tute EU citizens the risk of becoming victims of exploitation, but they also face xenophobia. While the economic crisis and auste-rity measures have resulted in an overall increase in unmet health needs in most countries, the most destitute – including an in-creasing number of nationals – have been hit the hardest. In total, 6.4% of the patients seen in Europe were nationals (up to 30.7% in Greece and 16.5% in Germany), 15.6% were migrant EU citizens (up to 53.3% in Germany) and 78% of all patients seen were from outside the EU/third-country nationals01.
Altogether, 62.9% of the people seen by MdM in Europe had no healthcare coverage. Children’s right to healthcare is one of the most basic, universal and essential human rights. And yet less than half of the children seen in MdM consultations were proper-ly immunised against tetanus (42.5%) or measles, mumps and rubella (34.5%) – although these vaccinations are known to be essential throughout the world and the vaccination coverage for measles at the age of two years is around 90% in the general po-pulation in Europe. More than half of the pregnant women had not had access to antenatal care before they came to MdM (54.2%). Of those, the majority came to receive care too late - that is after the 12th week of pregnancy (58.2%). A large majority of pregnant women had no healthcare coverage (81.1%), were living below the poverty line and 30.3% reported poor levels of moral support.
01 Third-country nationals refer to anyone who is not a citizen of one of the 28 European Union Member States.
The reported barriers to healthcare, as well as the analysis of the legal frameworks in the countries surveyed, confirm that restric-tive laws and complex administrarestric-tive processes to obtain access to care actually contribute to making people sicker. As in previous surveys, the barriers to accessing healthcare most often cited were financial inability to pay, administrative problems, lack of knowledge or understanding of the healthcare system and rights to care, and language barriers. It is thus hardly surprising that one patient in five said s/he had given up trying to access care or treatment in the last 12 months.
The data collected clearly deconstruct the myth of migration for health reasons, so often used by governments to restrict access to care. The migrants encountered in 2014 had been living in the ‘host country’ for 6.5 years on average before consulting MdM. Only 3% quoted health as one of the reasons for migration. Among the migrants who suffered from chronic diseases, only 9.5% knew they were ill before arriving in Europe.
European and national migration policies focus heavily on migra-tion as a ‘security issue’, thereby forgetting their duty to protect. An overwhelming majority of patients (84.4%) questioned on their experience of violence reported that they had suffered at least one violent experience, whether in their country of origin, during the journey or in the host country. They need extra care and safe surroundings to rebuild their lives, instead of too often living in ditches and slums in fear of expulsion.
EU Member States and institutions must offer universal public health systems built on solidarity, equality and equity (and not on profit rationale), open to everyone living in the EU. MdM urges Member States and EU institutions to ensure immediately that all children residing in the EU have full access to national immuni-sation programmes and to paediatric care. Similarly, all pregnant women must have access to termination of pregnancy, antenatal and postnatal care and safe delivery. In order to respect the ban on the death penalty, seriously ill migrants should never be ex-pelled to a country where effective access to adequate health-care cannot be guaranteed. They must be protected in Europe and have access to the care they need.
As health professionals, we will continue to give appropriate me-dical care to all people regardless of their administrative or social status and the existing legal barriers. MdM refuses all restrictive legal measures to alter medical ethics and exhorts all health pro-fessionals to provide care to all patients.
ExEcutivE summary
2014 in figurEs
23,040 patients seen in face-to-face medical and social
consultations in 25 cities in Belgium, France, Germany, Greece, the Netherlands, Spain, Sweden, Switzerland, the United Kingdom and Turkey, of whom 22,171 patients were seen in the nine European countries-> 8,656 were women
->
42,534
social and medical consultations, of which41,238
in the nine European countries->
23,240
diagnoses in the nine European countriesOf the
310
pregnant wOmen seen in eurOpe:
->
54.2% had no access to antenatal care
->
58.2%
came to receive care too late – after the 12th week of pregnancy (among those who had not accessed antenatal care prior to consulting MdM)->
81.1% had no health coverage
->89.2% lived below the poverty line
->52.4% did not have the right to reside
->
55.3%
were living in temporary accommodation and8.1%
were homeless->
30.3%
reported poor levels of moral support->
47.5%
were living apart from one or more of their minor children-> In Istanbul, 98% of the pregnant women seen had no healthcare coverage
Of the
623
children seen in eurOpe:
-> Only
42.5%
had been vaccinated against tetanus (69.7% in Greece)-> Only
34.5%
had been vaccinated against mumps, measles and rubella (MMR) (57.6% in Greece)->
38.8%
of patients did not know where to go to get their children vaccinatedOf all the peOple seen in the nine eurOpean
cOuntries:
->
43% were women
-> The median age was 35.8 ->93.6% were foreign citizens:
• 15.6% were migrant EU citizens and 78% citizens of non-EU countries
• 6.4% of the patients seen were nationals (up to 30.7% in Greece and 16.5% in Germany)
-> Foreign citizens had been living in the surveyed country for 6.5 years on average before consulting MdM ->
91.3% were living below the poverty line
->
64.7%
of patients were living in unstable or temporary accommodation and9.7%
were homeless->
29.5%
declared their accommodation to be harmful to their health or that of their children->
18.4%
never had someone they could rely on and were thus completely isolated->
50.2%
had migrated for economic reasons,28.2%
for political reasons and22.4%
for family reasons: only3% had migrated for health reasons
->
34% had the right to reside in Europe
->
43.4%
were or had been involved in an asylum applica-tion84.4%
Of the patients whO were questiOned
On the issue repOrted that they had suffered
at least One viOlent experience:
->
52.1%
had lived in a country at war->
39.1%
reported violence by the police or armed forces ->37.6%
of women reported sexual assault and24.1%
hadbeen raped
->
10%
reported violence in the host countryhealth status
->
22.9% of patients perceived their physical health as
bad or very bad. When it comes to mental health, this
goes up to 27.1%
->
70.2% hadn’t received medical attention before going
to MdM among patients who suffered from one or more chronic condition(s)-> Only
9.5% of migrants who suffered from chronic
di-seases knew about them before coming to Europe ->57.9% had at least one health problem needing treatment
that had never been treated before their consultation at MdM
Barriers tO accessing healthcare
->
62.9% of the people seen in Europe had no healthcare
coverage-> The most often cited barriers to accessing healthcare were financial problems in paying for care (27.9%), ad-ministrative problems (21.9%) and lack of knowledge or understanding of the healthcare system and of their rights (14.1%).
->
54.8% needed an interpreter.
-> During the previous 12 months:• 20.4% had given up seeking medical care or treatment • 15.2% had been denied care on at least one occasion • 4.5% had experienced racism in a healthcare setting ->
52% of patients without permission to reside said they
Europe is the cradle of human rights. Indeed, the range of inter-national texts and State commitments that ensure people’s basic and universal rights is impressive. With regard to healthcare, Eu-ropean Union institutions recently reaffirmed their adherence to the values of universality, access to good quality care, equity and solidarity. Yet, this report shows how, in practice, these promises too often remain just words rather than effective progress. Doctors of the World – Médecins du monde (MdM) teams are dis-tinctive because they work both on international programmes and at home. Abroad, MdM is active in many of the places in the world from which people try and escape to survive. At home, we provide freely accessible frontline medical and social services to anyone who faces barriers to the mainstream healthcare system. This re-port is based on data collected in 2014 in face-to-face medical and social consultations with 23,040 people in 25 programmes/ cities in Belgium, France, Germany, Greece, the Netherlands, Spain, Sweden, Switzerland, the United Kingdom and Turkey. It paints a bleak picture of the ‘cradle of human rights’.
Increasingly dangerous migration routes due to tightening border controls, sub-standard detention conditions and a life in fear of being expelled await most of the migrants who decide to seek safety and refuge in Europe. They have in common with desti-tute EU citizens the risk of becoming victims of exploitation, but they also face xenophobia. While the economic crisis and auste-rity measures have resulted in an overall increase in unmet health needs in most countries, the most destitute – including an in-creasing number of nationals – have been hit the hardest. In total, 6.4% of the patients seen in Europe were nationals (up to 30.7% in Greece and 16.5% in Germany), 15.6% were migrant EU citizens (up to 53.3% in Germany) and 78% of all patients seen were from outside the EU/third-country nationals01.
Altogether, 62.9% of the people seen by MdM in Europe had no healthcare coverage. Children’s right to healthcare is one of the most basic, universal and essential human rights. And yet less than half of the children seen in MdM consultations were proper-ly immunised against tetanus (42.5%) or measles, mumps and rubella (34.5%) – although these vaccinations are known to be essential throughout the world and the vaccination coverage for measles at the age of two years is around 90% in the general po-pulation in Europe. More than half of the pregnant women had not had access to antenatal care before they came to MdM (54.2%). Of those, the majority came to receive care too late - that is after the 12th week of pregnancy (58.2%). A large majority of pregnant women had no healthcare coverage (81.1%), were living below the poverty line and 30.3% reported poor levels of moral support.
01 Third-country nationals refer to anyone who is not a citizen of one of the 28 European Union Member States.
The reported barriers to healthcare, as well as the analysis of the legal frameworks in the countries surveyed, confirm that restric-tive laws and complex administrarestric-tive processes to obtain access to care actually contribute to making people sicker. As in previous surveys, the barriers to accessing healthcare most often cited were financial inability to pay, administrative problems, lack of knowledge or understanding of the healthcare system and rights to care, and language barriers. It is thus hardly surprising that one patient in five said s/he had given up trying to access care or treatment in the last 12 months.
The data collected clearly deconstruct the myth of migration for health reasons, so often used by governments to restrict access to care. The migrants encountered in 2014 had been living in the ‘host country’ for 6.5 years on average before consulting MdM. Only 3% quoted health as one of the reasons for migration. Among the migrants who suffered from chronic diseases, only 9.5% knew they were ill before arriving in Europe.
European and national migration policies focus heavily on migra-tion as a ‘security issue’, thereby forgetting their duty to protect. An overwhelming majority of patients (84.4%) questioned on their experience of violence reported that they had suffered at least one violent experience, whether in their country of origin, during the journey or in the host country. They need extra care and safe surroundings to rebuild their lives, instead of too often living in ditches and slums in fear of expulsion.
EU Member States and institutions must offer universal public health systems built on solidarity, equality and equity (and not on profit rationale), open to everyone living in the EU. MdM urges Member States and EU institutions to ensure immediately that all children residing in the EU have full access to national immuni-sation programmes and to paediatric care. Similarly, all pregnant women must have access to termination of pregnancy, antenatal and postnatal care and safe delivery. In order to respect the ban on the death penalty, seriously ill migrants should never be ex-pelled to a country where effective access to adequate health-care cannot be guaranteed. They must be protected in Europe and have access to the care they need.
As health professionals, we will continue to give appropriate me-dical care to all people regardless of their administrative or social status and the existing legal barriers. MdM refuses all restrictive legal measures to alter medical ethics and exhorts all health pro-fessionals to provide care to all patients.
ExEcutivE summary
2014 in figurEs
23,040 patients seen in face-to-face medical and social
consultations in 25 cities in Belgium, France, Germany, Greece, the Netherlands, Spain, Sweden, Switzerland, the United Kingdom and Turkey, of whom 22,171 patients were seen in the nine European countries-> 8,656 were women
->
42,534
social and medical consultations, of which41,238
in the nine European countries->
23,240
diagnoses in the nine European countriesOf the
310
pregnant wOmen seen in eurOpe:
->
54.2% had no access to antenatal care
->
58.2%
came to receive care too late – after the 12th week of pregnancy (among those who had not accessed antenatal care prior to consulting MdM)->
81.1% had no health coverage
->89.2% lived below the poverty line
->52.4% did not have the right to reside
->
55.3%
were living in temporary accommodation and8.1%
were homeless->
30.3%
reported poor levels of moral support->
47.5%
were living apart from one or more of their minor children-> In Istanbul, 98% of the pregnant women seen had no healthcare coverage
Of the
623
children seen in eurOpe:
-> Only
42.5%
had been vaccinated against tetanus (69.7% in Greece)-> Only
34.5%
had been vaccinated against mumps, measles and rubella (MMR) (57.6% in Greece)->
38.8%
of patients did not know where to go to get their children vaccinatedOf all the peOple seen in the nine eurOpean
cOuntries:
->
43% were women
-> The median age was 35.8 ->93.6% were foreign citizens:
• 15.6% were migrant EU citizens and 78% citizens of non-EU countries
• 6.4% of the patients seen were nationals (up to 30.7% in Greece and 16.5% in Germany)
-> Foreign citizens had been living in the surveyed country for 6.5 years on average before consulting MdM ->
91.3% were living below the poverty line
->
64.7%
of patients were living in unstable or temporary accommodation and9.7%
were homeless->
29.5%
declared their accommodation to be harmful to their health or that of their children->
18.4%
never had someone they could rely on and were thus completely isolated->
50.2%
had migrated for economic reasons,28.2%
for political reasons and22.4%
for family reasons: only3% had migrated for health reasons
->
34% had the right to reside in Europe
->
43.4%
were or had been involved in an asylum applica-tion84.4%
Of the patients whO were questiOned
On the issue repOrted that they had suffered
at least One viOlent experience:
->
52.1%
had lived in a country at war->
39.1%
reported violence by the police or armed forces ->37.6%
of women reported sexual assault and24.1%
hadbeen raped
->
10%
reported violence in the host countryhealth status
->
22.9% of patients perceived their physical health as
bad or very bad. When it comes to mental health, this
goes up to 27.1%
->
70.2% hadn’t received medical attention before going
to MdM among patients who suffered from one or more chronic condition(s)-> Only
9.5% of migrants who suffered from chronic
di-seases knew about them before coming to Europe ->57.9% had at least one health problem needing treatment
that had never been treated before their consultation at MdM
Barriers tO accessing healthcare
->
62.9% of the people seen in Europe had no healthcare
coverage-> The most often cited barriers to accessing healthcare were financial problems in paying for care (27.9%), ad-ministrative problems (21.9%) and lack of knowledge or understanding of the healthcare system and of their rights (14.1%).
->
54.8% needed an interpreter.
-> During the previous 12 months:• 20.4% had given up seeking medical care or treatment • 15.2% had been denied care on at least one occasion • 4.5% had experienced racism in a healthcare setting ->
52% of patients without permission to reside said they
introduction
to the 2014 survey
the cOntext In 2014
the cOntInuIng effects Of the ecOnOmIc crIsIs
Health expenditure fell in half of the European Union countries between 2009 and 2012, and significantly slowed in the rest of Eu-rope02. The public share of total spending on health globally declined between 2007 and 201203. At the same time, the overall population’s unmet needs for medical examination are on the rise in most Euro-pean countries and have nearly doubled since the beginning of the crisis in Greece and Spain04.
The crisis has led the World Health Organization (WHO) to (re)confirm that “health systems generally need more, not fewer, resources in an
economic crisis”05. In the same document, WHO notes that measuring
the impact that the economic crisis has had on healthcare systems remains difficult, because of time lags in the availability of interna-tional data and in the effects of both the crisis and policy responses to counter these negative effects. It also continues to be difficult because the adverse effects on population groups already facing vulnerability factors can remain unseen in public health information systems or surveys.
In recent decades, a number of Member States have introduced or increased out-of-pocket payments for health with the objective of making patients ‘more responsible’ – thereby reducing the demand for healthcare and direct public health costs. Yet, co-payment has been proven to be administratively complex06. In addition, it does not au-tomatically decrease the overall utilisation of healthcare services07, and does not necessarily incite users to make more rational use of healthcare. Furthermore, it has been shown that destitute people or people with greater health needs (such as the chronically ill) are more affected by co-payment schemes08. Consequently, WHO warns that user fees should be used with great caution in view of their detrimen-tal effects on vulnerable populations09.
02 OECD. Health at a glance: Europe 2014. Paris: OECD, 2014.
03 European Observatory on Health Systems and Policies. Economic crisis, health systems and health in Europe: impact and implications for policy. Geneva: WHO, 2014.
04 Eurostat. Self-reported unmet needs for medical examination, by sex, age and reason. 2015. Last accessed on 17/02/2015.
05 European Observatory on Health Systems and Policies. op. cit.
06 Dourgnon P, Grignon M. Le tiers-payant est-il inflationniste? Etude de l’influence du recours au tiers-payant sur la dépense de santé. Paris: CREDES, 2000.
07 Barer ML, Evans RG, Stoddart GL. Controlling health care costs by direct charges to patients: Snare or delusion? Toronto: Ontario, Economic Council, occasional paper 10, 1979.
Hurley J, Arbuthnot Johnson N. The Effects of Co-Payments Within Drug Reimbursement Programs. Canadian Public Policy 1991; 17: 473-89.
08 Majnoni d’Intignano B. Analyse des derniers développements et des réformes en matière de financement des systèmes de santé. Revue internationale de sécurité sociale 1991; 44: 10-1. Newhouse JP and the Insurance Experiment Group. Free for all? Lessons from the RAND Health Expe-riment. Cambridge, MA: Harvard University Press, 1993.
09 CSDH. Closing the gap in a generation: Health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva: WHO, 2008.
The researchers at the WHO European Observatory on Health Systems and Policies noted that many of the countries at risk of inadequate levels of public funding following the crisis are actually EU countries, further adding that: “the important economic and social benefits of public spending on health have not been sufficiently acknowledged in fiscal policy decisions and EU-IMF Economic Adjustment Programmes”. The Organisation for Economic Co-operation and Development (OECD) recently warned that the gap between rich and poor is at its highest level in most OECD countries in 30 years10. “Not only cash transfers but also increasing access to public services, such as high-quality educa-tion, training and healthcare, constitute long-term social investment to create greater equality of opportunities in the long run”.
greece: the sItuatIOn remaIns partIcularly wOrryIng
Although the aftermath of the financial and economic crisis that started in 2008 is still being felt across healthcare systems throughout Europe, some countries have been hit more severely than others11. In Greece, 2.5 million people live below the poverty line (23.1% of the total population)12. Moreover, 27.3% of the total population live in over-crowded households, 29.4% state that they are unable to keep their home adequately warm, and 57.9% of the destitute population report that they are being confronted with payment arrears for electricity, water, gas, etc13. Crisis and austerity policies have left almost a third of the population without healthcare coverage14. Unemployment stood at 25.8% in December 201415, unemployment benefits were limited to 12 months16, after which there was no minimum income guarantee17. The percentage of people reporting unmet medical care needs has increased since the beginning of the crisis, rising from around 5.4% of the population in 2008 to 9% in 201318.
10 OECD. Focus on inequality and growth. OECD Directorate for Employment, Labour and Social Af-fairs. Paris: OECD. December 2014.
11 Eurofound. Access to healthcare in times of crisis. Dublin, 2014.
12 Collective. Statistics on income and living conditions 2013. Athens: Hellenic Statistical Authority, 2013.
13 Press release (13/10/2014) by the Hellenic Statistical Authority – Statistics on income and living conditions 2013 (income reference period 2012).
14 OECD Directorate for Employment, Labour and Social Affairs. op. cit..
15 http://ec.europa.eu/eurostat/statistics-explained/index.php/Unemployment_statistics 16 European Commission. Your social security rights in Greece. Brussels, 2013.
17 In 2012, only 20,000 persons (3% of unemployed) could benefit from the long term unemploye-ment assistance thanks to the raised income threshold. Koutsogeorgopoulou V et al. Fairly sharing the social impact of the crisis in Greece. OECD Economics Department; 9 January 2014, p36. 18 Eurostat. Self-reported unmet needs for medical examination, by sex, age and reason. 2015. op.cit.
contents
2.
executIve summary
5.
IntrOductIOn tO the 2014 survey
12.
methOds
13.
fOcus On pregnant wOmen
18.
fOcus On chIldhOOd vaccInatIOn
22.
demOgraphIc characterIstIcs
22.
sex and age22.
natIOnalIty and geOgraphIcal OrIgIn25.
length Of stay By fOreIgn natIOnalsIn the survey cOuntry
25.
reasOns fOr mIgratIOn28.
admInIstratIve sItuatIOn
30.
lIvIng cOndItIOns
30.
hOusIng cOndItIOns31.
wOrk and IncOme31.
sOcIal IsOlatIOn32.
access tO healthcare
32.
cOverage Of healthcare charges34.
BarrIers In access tO healthcare35.
gIvIng up seekIng healthcare35.
denIal Of access tO healthcare36.
racIsm In healthcare servIces36.
fear Of BeIng arrested37.
experIences Of vIOlence
40.
health status
40.
self-perceIved health status40.
chrOnIc health cOndItIOns41.
urgent care and essentIal treatment41.
patIents whO had receIved lIttle healthcare BefOre cOmIng tO mdm41.
health prOBlems largely unknOwn prIOr tO arrIval In eurOpe42.
health prOBlems By Organ system44.
cOnclusIOn
introduction
to the 2014 survey
the cOntext In 2014
the cOntInuIng effects Of the ecOnOmIc crIsIs
Health expenditure fell in half of the European Union countries between 2009 and 2012, and significantly slowed in the rest of Eu-rope02. The public share of total spending on health globally declined between 2007 and 201203. At the same time, the overall population’s unmet needs for medical examination are on the rise in most Euro-pean countries and have nearly doubled since the beginning of the crisis in Greece and Spain04.
The crisis has led the World Health Organization (WHO) to (re)confirm that “health systems generally need more, not fewer, resources in an
economic crisis”05. In the same document, WHO notes that measuring
the impact that the economic crisis has had on healthcare systems remains difficult, because of time lags in the availability of interna-tional data and in the effects of both the crisis and policy responses to counter these negative effects. It also continues to be difficult because the adverse effects on population groups already facing vulnerability factors can remain unseen in public health information systems or surveys.
In recent decades, a number of Member States have introduced or increased out-of-pocket payments for health with the objective of making patients ‘more responsible’ – thereby reducing the demand for healthcare and direct public health costs. Yet, co-payment has been proven to be administratively complex06. In addition, it does not au-tomatically decrease the overall utilisation of healthcare services07, and does not necessarily incite users to make more rational use of healthcare. Furthermore, it has been shown that destitute people or people with greater health needs (such as the chronically ill) are more affected by co-payment schemes08. Consequently, WHO warns that user fees should be used with great caution in view of their detrimen-tal effects on vulnerable populations09.
02 OECD. Health at a glance: Europe 2014. Paris: OECD, 2014.
03 European Observatory on Health Systems and Policies. Economic crisis, health systems and health in Europe: impact and implications for policy. Geneva: WHO, 2014.
04 Eurostat. Self-reported unmet needs for medical examination, by sex, age and reason. 2015. Last accessed on 17/02/2015.
05 European Observatory on Health Systems and Policies. op. cit.
06 Dourgnon P, Grignon M. Le tiers-payant est-il inflationniste? Etude de l’influence du recours au tiers-payant sur la dépense de santé. Paris: CREDES, 2000.
07 Barer ML, Evans RG, Stoddart GL. Controlling health care costs by direct charges to patients: Snare or delusion? Toronto: Ontario, Economic Council, occasional paper 10, 1979.
Hurley J, Arbuthnot Johnson N. The Effects of Co-Payments Within Drug Reimbursement Programs. Canadian Public Policy 1991; 17: 473-89.
08 Majnoni d’Intignano B. Analyse des derniers développements et des réformes en matière de financement des systèmes de santé. Revue internationale de sécurité sociale 1991; 44: 10-1. Newhouse JP and the Insurance Experiment Group. Free for all? Lessons from the RAND Health Expe-riment. Cambridge, MA: Harvard University Press, 1993.
09 CSDH. Closing the gap in a generation: Health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva: WHO, 2008.
The researchers at the WHO European Observatory on Health Systems and Policies noted that many of the countries at risk of inadequate levels of public funding following the crisis are actually EU countries, further adding that: “the important economic and social benefits of public spending on health have not been sufficiently acknowledged in fiscal policy decisions and EU-IMF Economic Adjustment Programmes”. The Organisation for Economic Co-operation and Development (OECD) recently warned that the gap between rich and poor is at its highest level in most OECD countries in 30 years10. “Not only cash transfers but also increasing access to public services, such as high-quality educa-tion, training and healthcare, constitute long-term social investment to create greater equality of opportunities in the long run”.
greece: the sItuatIOn remaIns partIcularly wOrryIng
Although the aftermath of the financial and economic crisis that started in 2008 is still being felt across healthcare systems throughout Europe, some countries have been hit more severely than others11. In Greece, 2.5 million people live below the poverty line (23.1% of the total population)12. Moreover, 27.3% of the total population live in over-crowded households, 29.4% state that they are unable to keep their home adequately warm, and 57.9% of the destitute population report that they are being confronted with payment arrears for electricity, water, gas, etc13. Crisis and austerity policies have left almost a third of the population without healthcare coverage14. Unemployment stood at 25.8% in December 201415, unemployment benefits were limited to 12 months16, after which there was no minimum income guarantee17. The percentage of people reporting unmet medical care needs has increased since the beginning of the crisis, rising from around 5.4% of the population in 2008 to 9% in 201318.
10 OECD. Focus on inequality and growth. OECD Directorate for Employment, Labour and Social Af-fairs. Paris: OECD. December 2014.
11 Eurofound. Access to healthcare in times of crisis. Dublin, 2014.
12 Collective. Statistics on income and living conditions 2013. Athens: Hellenic Statistical Authority, 2013.
13 Press release (13/10/2014) by the Hellenic Statistical Authority – Statistics on income and living conditions 2013 (income reference period 2012).
14 OECD Directorate for Employment, Labour and Social Affairs. op. cit..
15 http://ec.europa.eu/eurostat/statistics-explained/index.php/Unemployment_statistics 16 European Commission. Your social security rights in Greece. Brussels, 2013.
17 In 2012, only 20,000 persons (3% of unemployed) could benefit from the long term unemploye-ment assistance thanks to the raised income threshold. Koutsogeorgopoulou V et al. Fairly sharing the social impact of the crisis in Greece. OECD Economics Department; 9 January 2014, p36. 18 Eurostat. Self-reported unmet needs for medical examination, by sex, age and reason. 2015. op.cit.
contents
2.
executIve summary
5.
IntrOductIOn tO the 2014 survey
12.
methOds
13.
fOcus On pregnant wOmen
18.
fOcus On chIldhOOd vaccInatIOn
22.
demOgraphIc characterIstIcs
22.
sex and age22.
natIOnalIty and geOgraphIcal OrIgIn25.
length Of stay By fOreIgn natIOnalsIn the survey cOuntry
25.
reasOns fOr mIgratIOn28.
admInIstratIve sItuatIOn
30.
lIvIng cOndItIOns
30.
hOusIng cOndItIOns31.
wOrk and IncOme31.
sOcIal IsOlatIOn32.
access tO healthcare
32.
cOverage Of healthcare charges34.
BarrIers In access tO healthcare35.
gIvIng up seekIng healthcare35.
denIal Of access tO healthcare36.
racIsm In healthcare servIces36.
fear Of BeIng arrested37.
experIences Of vIOlence
40.
health status
40.
self-perceIved health status40.
chrOnIc health cOndItIOns41.
urgent care and essentIal treatment41.
patIents whO had receIved lIttle healthcare BefOre cOmIng tO mdm41.
health prOBlems largely unknOwn prIOr tO arrIval In eurOpe42.
health prOBlems By Organ system44.
cOnclusIOn
Mare Nostrum ceased at the end of 2014. At the moment, the only initiative in place is the European down-scaled Frontex operation, Tri-ton, the main focus of which is border management. Its more limited resources, mandate and geographical coverage (only within 30 miles of the Italian coast) have resulted in a downsizing of the search and rescue efforts. This means that many more people risk dying in their attempt to reach Europe, as the flows of migrants and therefore the risk of shipwrecks will not decrease in the Mediterranean30.
rIsIng IntOlerance
Instead of focusing on the needs of vulnerable refugees, the Euro-pean Council launched a joint police and border guard operation Mos Maiorum that took place over two weeks in October 2014. Although this joint operation was focused on apprehending ‘irregular’ migrants and their facilitators, a quarter of the people encountered by the authori-ties were Syrian asylum seekers31.
Although migrants contribute more in taxes and social contributions than they receive in benefits32, and clearly make positive fiscal contri-butions33, they are often falsely described as ‘benefit-oriented’. Fur-thermore, the crisis has first and foremost hit foreign-born workers: despite identical participation rates in the labour force across OECD countries, the average unemployment rate among foreign-born wor-kers (13%) is significantly higher than that of native-born worwor-kers (9%).
30 ECRE, Weekly bulletin, 10/10/2014. www.ecre.org/component/content/article/70-weekly-bulle- tin-articles/855-operation-mare-nostrum-to-end-frontex-triton-operation-will-not-ensure-rescue-at-sea-of-migrants-in-international-waters.html
31 www.statewatch.org/news/2015/jan/eu-council-2015-01-22-05474-mos-maiorum-final-report.pdf 32 OECD. Is migration good for the economy? Migration policy debates. Paris: OCDE, May 2014. 33 Dustmann C, Frattini T. The fiscal effects of immigration to the UK. The Economic Journal, in press.
These differences are most salient in Greece and Spain (respectively 26% and 24% unemployment among native-born compared with 38% and 36% among foreign-born workers)34.
During last year’s European Parliamentary elections, the European Network Against Racism (ENAR) and the International Lesbian, Gay, Bisexual, Trans and Intersex Association (ILGA Europe) registered 42 hate speech incidents against minorities (migrants, LGBTI, Muslims and Roma)35 by election candidates, five of whom currently sit in the newly elected Parliament.
In February 2015, Nils Muižnieks, the Council of Europe Commissioner for Human Rights, denounced the fact that “despite advances in legisla-tion and measures to combat intolerance and racism, discriminalegisla-tion and hate speech not only persist in France but are on the rise. […] In recent years, there has been a huge increase in anti-Semitic, anti-Muslim and homophobic acts. In the first half of 2014 alone, the number of anti-Semi-tic acts virtually doubled. […] The rising number of anti-Muslim acts, 80% of which are carried out against women, and homophobic acts, which
occur once every two days, is also cause for great concern.”36
34 OECD data on migration for 2013: https://data.oecd.org/migration/foreign-born-participation- rates.htm#indicator-chart, last accessed on 17/02/2015.
35 ENAR / ILGA Europe (July 2014). http://www.enar-eu.org/IMG/pdf/nohateep2014_report_-_3_july.pdf 36 CoE. Press release, France: persistent discrimination endangers human rights. 2015.
The crisis in Greece also had impacts on the number of drug users, the rates of HIV and hepatitis C (HCV) among them, and the type of drugs used. For example, the affordable drug sisa (methamphetamine mixed with other dangerous substances) is having devastating effects among drug users. A recent study estimated the Greek prevalence for HCV at 1.87%, while almost 80% of chronic HCV patients may not be aware of their infection, and only 58% of diagnosed chronic HCV pa-tients had ever been treated19.
the Impact Of the crIsIs On chIldren
An estimated 27 million children in Europe are at risk of poverty or social exclusion, with the economic and social crisis further increa-sing their vulnerability20. The national data collected by UNICEF clearly show the harmful impact of the crisis. Some 1.6 million more children were living in severe material deprivation in 2012 than in 2008 (an in-crease from 9.5 million to 11.1 million) in 30 European countries. The number of children entering into poverty during the crisis is 2.6 million higher than the number of those who have been able to escape po-verty since 2008. Child popo-verty rates are soaring in Greece (40.5% in 2012 compared with 23% in 2008) and Spain (36.3% in 2012 compared with 28.2% in 2008)21.
The latest available OECD data22 indicate a rise in the number of low-birth-weight babies by more than 16% between 2008 and 2011, which has long-term implications for child health and development. Obste-tricians have reported a 32% rise in stillbirths in Greece between 2008 and 2010, while fewer pregnant women have access to antenatal care services23.
mIgrants In danger at eurOpe’s BOrders
In recent years, there has been a significant rise in the number of inter-nal armed conflicts and other forms of violent situations leading to mass displacement within or across borders, e.g. in Afghanistan, the Central African Republic, Eritrea, Iraq, Libya, Pakistan, South Sudan and Syria, to name but a few. Besides the direct impact of violence, many other factors endanger the populations in these countries, such as increasing poverty, food insecurity and hunger, as well as increasing risks of public health problems.
Although countries in North Africa, the Middle East and East Africa have been hosting the majority of the millions of displaced persons, there has also been a gradual increase in the number of asylum applications in the 28 Member States of the EU, to 626,820 in 201424 - an increase of more than 40% compared to 2013 according to UNHCR25. The fact that asylum seekers cannot freely choose where to lodge an asylum application (because the Dublin III regulation requires to request asylum in the EU country where asylum seekers arrived first) has serious consequences for their well-being and mental health. It also shows the clear lack of soli-darity between Member States when it comes to migration issues.
19 Papatheodoridis G, Sypsa V, Kantzanou M, Nikolakopoulos I, Hatzakis A. Estimating the treatment cascade of chronic hepatitis B and C in Greece using a telephone survey. J VIral Hep 2015; 22: 409–15. 20 Save the Children. Child poverty and social exclusion in Europe: A matter of children’s rights. Brussels: Save the Children, 2014.
21 UNICEF Office of Research. Children of the Recession: The impact of the economic crisis on child well-being in rich countries. Florence: UNICEF Office of Research, 2014.
22 OECD data: http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT. Last accessed on
16/02/2014.
23 Vlachadis N, Kornarou E. Increase in stillbirths in Greece is linked to the economic crisis. BMJ 2013; 346: f1061.
24 Eurostat (2014),
www.ec.europa.eu/eurostat/tgm/table.do?tab=table&init=1&language=en&pcode=tps00191&plugin=1. Last accessed 18/03/2015
25 UNHCR. Asylum Trends 2014: Levels and Trends in Industrialized Countries. Geneva: UNHCR, 2015. http://www.unhcr.org/551128679.html
The effects of the increase in the number of asylum seekers in Europe were directly observed by MdM teams in Switzerland, where two additio-nal asylum seeker centres were opened in 2014. In Munich the number of asylum seekers has almost doubled compared to 2013, temporarily leading to a situation whereby asylum seekers had to sleep in tents or outside, before new reception facilities were opened.
Since the start of the Syrian crisis, of the total estimated 11.4 million Syrians who have fled their homes (over half of the total Syrian popu-lation), 3.8 million took refuge in neighbouring countries and 7.6 million were internally displaced26. Syrians were the largest group of people granted protection status in the EU-28 from 2012 to 2014; they also regis-tered the highest recognition rates afforded by EU Member States with over 90% positive decisions since 201227. However under 150,000 Syrians have sought asylum in the EU since the war began - less than 4 % of the conflict’s total refugee population - and the majority of Syrians were resettled in two countries, Germany and Sweden28.
Due to controls and walls on land migration routes, many migrants try to reach Europe through the Mediterranean Sea. In December 2014, the UN-HCR estimated their total annual number at 200,000 (compared to 60,000 in 2013). Among those seeking a better future in Europe are large numbers of unaccompanied minors. In Italy and Malta alone, over 23,800 children had arrived by sea, including at least 12,000 unaccompanied, during the first nine months of 201429. While 150,000 migrants were rescued under the Mare Nostrum operation, UNHCR estimates that around 3,400 people have died or have gone missing at sea (data as of November 2014).
26 www.unocha.org/syria
27 European Commission. Facts and figures on the arrivals of migrants in Europe, Fact Sheet (13/01/2015)
28 ECRE / ELENA. http://www.ecre.org/component/downloads/downloads/824.html Information note on Syrian asylum seekers and refugees in Europe. 2013; and EUROSTAT: http:// ec.europa.eu/eurostat/statistics-explained/index.php/Asylum_quarterly_report)
29 UNHCR. So close, yet so far from safety, The Central Mediterranean Sea Initiative. 2014.
© MdM
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dANgEroUS MIgrATIoN roUTES, EvEN IN ‘hoST’ coUNTrIES... cALAIS – FrANcE – 2014
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Mare Nostrum ceased at the end of 2014. At the moment, the only initiative in place is the European down-scaled Frontex operation, Tri-ton, the main focus of which is border management. Its more limited resources, mandate and geographical coverage (only within 30 miles of the Italian coast) have resulted in a downsizing of the search and rescue efforts. This means that many more people risk dying in their attempt to reach Europe, as the flows of migrants and therefore the risk of shipwrecks will not decrease in the Mediterranean30.
rIsIng IntOlerance
Instead of focusing on the needs of vulnerable refugees, the Euro-pean Council launched a joint police and border guard operation Mos Maiorum that took place over two weeks in October 2014. Although this joint operation was focused on apprehending ‘irregular’ migrants and their facilitators, a quarter of the people encountered by the authori-ties were Syrian asylum seekers31.
Although migrants contribute more in taxes and social contributions than they receive in benefits32, and clearly make positive fiscal contri-butions33, they are often falsely described as ‘benefit-oriented’. Fur-thermore, the crisis has first and foremost hit foreign-born workers: despite identical participation rates in the labour force across OECD countries, the average unemployment rate among foreign-born wor-kers (13%) is significantly higher than that of native-born worwor-kers (9%).
30 ECRE, Weekly bulletin, 10/10/2014. www.ecre.org/component/content/article/70-weekly-bulle- tin-articles/855-operation-mare-nostrum-to-end-frontex-triton-operation-will-not-ensure-rescue-at-sea-of-migrants-in-international-waters.html
31 www.statewatch.org/news/2015/jan/eu-council-2015-01-22-05474-mos-maiorum-final-report.pdf 32 OECD. Is migration good for the economy? Migration policy debates. Paris: OCDE, May 2014. 33 Dustmann C, Frattini T. The fiscal effects of immigration to the UK. The Economic Journal, in press.
These differences are most salient in Greece and Spain (respectively 26% and 24% unemployment among native-born compared with 38% and 36% among foreign-born workers)34.
During last year’s European Parliamentary elections, the European Network Against Racism (ENAR) and the International Lesbian, Gay, Bisexual, Trans and Intersex Association (ILGA Europe) registered 42 hate speech incidents against minorities (migrants, LGBTI, Muslims and Roma)35 by election candidates, five of whom currently sit in the newly elected Parliament.
In February 2015, Nils Muižnieks, the Council of Europe Commissioner for Human Rights, denounced the fact that “despite advances in legisla-tion and measures to combat intolerance and racism, discriminalegisla-tion and hate speech not only persist in France but are on the rise. […] In recent years, there has been a huge increase in anti-Semitic, anti-Muslim and homophobic acts. In the first half of 2014 alone, the number of anti-Semi-tic acts virtually doubled. […] The rising number of anti-Muslim acts, 80% of which are carried out against women, and homophobic acts, which
occur once every two days, is also cause for great concern.”36
34 OECD data on migration for 2013: https://data.oecd.org/migration/foreign-born-participation- rates.htm#indicator-chart, last accessed on 17/02/2015.
35 ENAR / ILGA Europe (July 2014). http://www.enar-eu.org/IMG/pdf/nohateep2014_report_-_3_july.pdf 36 CoE. Press release, France: persistent discrimination endangers human rights. 2015.
The crisis in Greece also had impacts on the number of drug users, the rates of HIV and hepatitis C (HCV) among them, and the type of drugs used. For example, the affordable drug sisa (methamphetamine mixed with other dangerous substances) is having devastating effects among drug users. A recent study estimated the Greek prevalence for HCV at 1.87%, while almost 80% of chronic HCV patients may not be aware of their infection, and only 58% of diagnosed chronic HCV pa-tients had ever been treated19.
the Impact Of the crIsIs On chIldren
An estimated 27 million children in Europe are at risk of poverty or social exclusion, with the economic and social crisis further increa-sing their vulnerability20. The national data collected by UNICEF clearly show the harmful impact of the crisis. Some 1.6 million more children were living in severe material deprivation in 2012 than in 2008 (an in-crease from 9.5 million to 11.1 million) in 30 European countries. The number of children entering into poverty during the crisis is 2.6 million higher than the number of those who have been able to escape po-verty since 2008. Child popo-verty rates are soaring in Greece (40.5% in 2012 compared with 23% in 2008) and Spain (36.3% in 2012 compared with 28.2% in 2008)21.
The latest available OECD data22 indicate a rise in the number of low-birth-weight babies by more than 16% between 2008 and 2011, which has long-term implications for child health and development. Obste-tricians have reported a 32% rise in stillbirths in Greece between 2008 and 2010, while fewer pregnant women have access to antenatal care services23.
mIgrants In danger at eurOpe’s BOrders
In recent years, there has been a significant rise in the number of inter-nal armed conflicts and other forms of violent situations leading to mass displacement within or across borders, e.g. in Afghanistan, the Central African Republic, Eritrea, Iraq, Libya, Pakistan, South Sudan and Syria, to name but a few. Besides the direct impact of violence, many other factors endanger the populations in these countries, such as increasing poverty, food insecurity and hunger, as well as increasing risks of public health problems.
Although countries in North Africa, the Middle East and East Africa have been hosting the majority of the millions of displaced persons, there has also been a gradual increase in the number of asylum applications in the 28 Member States of the EU, to 626,820 in 201424 - an increase of more than 40% compared to 2013 according to UNHCR25. The fact that asylum seekers cannot freely choose where to lodge an asylum application (because the Dublin III regulation requires to request asylum in the EU country where asylum seekers arrived first) has serious consequences for their well-being and mental health. It also shows the clear lack of soli-darity between Member States when it comes to migration issues.
19 Papatheodoridis G, Sypsa V, Kantzanou M, Nikolakopoulos I, Hatzakis A. Estimating the treatment cascade of chronic hepatitis B and C in Greece using a telephone survey. J VIral Hep 2015; 22: 409–15. 20 Save the Children. Child poverty and social exclusion in Europe: A matter of children’s rights. Brussels: Save the Children, 2014.
21 UNICEF Office of Research. Children of the Recession: The impact of the economic crisis on child well-being in rich countries. Florence: UNICEF Office of Research, 2014.
22 OECD data: http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT. Last accessed on
16/02/2014.
23 Vlachadis N, Kornarou E. Increase in stillbirths in Greece is linked to the economic crisis. BMJ 2013; 346: f1061.
24 Eurostat (2014),
www.ec.europa.eu/eurostat/tgm/table.do?tab=table&init=1&language=en&pcode=tps00191&plugin=1. Last accessed 18/03/2015
25 UNHCR. Asylum Trends 2014: Levels and Trends in Industrialized Countries. Geneva: UNHCR, 2015. http://www.unhcr.org/551128679.html
The effects of the increase in the number of asylum seekers in Europe were directly observed by MdM teams in Switzerland, where two additio-nal asylum seeker centres were opened in 2014. In Munich the number of asylum seekers has almost doubled compared to 2013, temporarily leading to a situation whereby asylum seekers had to sleep in tents or outside, before new reception facilities were opened.
Since the start of the Syrian crisis, of the total estimated 11.4 million Syrians who have fled their homes (over half of the total Syrian popu-lation), 3.8 million took refuge in neighbouring countries and 7.6 million were internally displaced26. Syrians were the largest group of people granted protection status in the EU-28 from 2012 to 2014; they also regis-tered the highest recognition rates afforded by EU Member States with over 90% positive decisions since 201227. However under 150,000 Syrians have sought asylum in the EU since the war began - less than 4 % of the conflict’s total refugee population - and the majority of Syrians were resettled in two countries, Germany and Sweden28.
Due to controls and walls on land migration routes, many migrants try to reach Europe through the Mediterranean Sea. In December 2014, the UN-HCR estimated their total annual number at 200,000 (compared to 60,000 in 2013). Among those seeking a better future in Europe are large numbers of unaccompanied minors. In Italy and Malta alone, over 23,800 children had arrived by sea, including at least 12,000 unaccompanied, during the first nine months of 201429. While 150,000 migrants were rescued under the Mare Nostrum operation, UNHCR estimates that around 3,400 people have died or have gone missing at sea (data as of November 2014).
26 www.unocha.org/syria
27 European Commission. Facts and figures on the arrivals of migrants in Europe, Fact Sheet (13/01/2015)
28 ECRE / ELENA. http://www.ecre.org/component/downloads/downloads/824.html Information note on Syrian asylum seekers and refugees in Europe. 2013; and EUROSTAT: http:// ec.europa.eu/eurostat/statistics-explained/index.php/Asylum_quarterly_report)
29 UNHCR. So close, yet so far from safety, The Central Mediterranean Sea Initiative. 2014.
© MdM
A SyrIAN chILd IN ThE MIgrANT rEcEPTIoN cENTrE AFTEr hAvINg jUST ArrIvEd by boAT IN LESboS - grEEcE - 2014
dANgEroUS MIgrATIoN roUTES, EvEN IN ‘hoST’ coUNTrIES... cALAIS – FrANcE – 2014
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